Opinion
DBDCV186028934S
10-02-2019
WESTERN CONNECTICUT HEALTH NETWORK v. Raymond AINGER, III
UNPUBLISHED OPINION
OPINION
D’Andrea, Robert A., Judge
This is a collections case stemming from a complaint, dated September 14, 2018, alleging that the plaintiff, Western Connecticut Health Network ("plaintiff") provided medical services and medication to the defendant, Raymond Ainger III ("defendant") with expectation of payment, and as of the date of trial, the defendant has not provided payment. The court has reviewed all the pleadings prior to the beginning of trial, and reviewed same again with exhibits after trial.
FACTS
The plaintiff provided various medical services and medication to the defendant on or about June 6 through June 9, 2016, which were provided to the defendant at its place of business in Danbury, Connecticut. The price of medical services and medication provided by the plaintiff was $17,650. As of the date of trial, defendant has not made payment, despite plaintiff’s efforts to collect the outstanding balance. Plaintiff, in its claim for relief, seeks money damages, costs of suit, prejudgment and postjudgment interest on the amount of damages, and an order of weekly payments by the defendant to be paid to the plaintiff.
The defendant at trial readily admitted that the plaintiff did provide medical services and medication to him, but disputes the amount of said medical services and medication owed to the plaintiff. The defendant, in his answer, and in his testimony at trial, indicated that he was covered by health insurance on the dates in question of June 6 through June 9, 2016, having paid all required health insurance premiums. At some point in the beginning of July 2016, the plaintiff’s health insurance was unexpectedly terminated retroactively to the end of May 2016, thus disallowing for payment of any medical services and medication rendered to, and received by the defendant, during the month of June 2016. Once he became aware of the lack of health insurance, the defendant cancelled any further medical services and medication from the plaintiff until he was able to obtain health insurance coverage.
LEGAL STANDARD
Plaintiff has the burden of proving the allegations of the complaint and the alleged damages by a fair preponderance of the evidence. In order to meet this burden of proof, the plaintiff must satisfy the court that its claims on an issue are more probable than not. A fair preponderance of the evidence means that the better or weightier evidence must establish that, more probably than not, the assertion(s) of the plaintiff is (are) true. As both plaintiff and defendant agree that the defendant was provided the medical services and medication claimed by the plaintiff, and that the plaintiff had demanded payment, and that the defendant has not provided payment. The court finds, by a fair preponderance of the evidence, that the plaintiff provided medical services and medication to the defendant from the time between June 6 through June 9, 2016, and the defendant has not made payment for said medical services and medication. The issue before the court is the amount of money that the defendant owes the plaintiff for the medical services and medication provided by the plaintiff to him.
PLAINTIFF’S POSITION
Plaintiff claims that it is statutorily obligated by General Statutes § § 19a-646(b) and 19a-681(a) to charge defendant the sum of $17,650 as shown in detail on its billing invoice dated September 19, 2016 (plaintiff’s exhibit 1) describing dates of service, description of hospital services, service codes, total charges and estimated coverage of insurance. "[I]n Connecticut the amount that a hospital may bill for a particular service is controlled by the ‘pricemaster’ pursuant to "chapters 368z and 368aa of the General Statutes ... General Statutes § 19a-681(c) imposes a severe penalty on a hospital for deviation from the ‘pricemaster.’" Stamford Hospital v. Chaim Schwartz, 190 Conn.App. 63, (05/21/2019), 209 A.3d 1243, cert. denied 332 Conn. 919 (06/26/2019). Section 19a-646 provides in relevant part: "(a)(4) ‘Payer’ means any person, legal entity, governmental body or eligible organization ... which is or may become legally responsible, in whole or in part for the payment of services rendered to or on behalf of a patient by a hospital." Defendant here is a "payer" legally responsible for the payment of plaintiff’s services rendered in June 2016. Had defendant been a covered person under any health benefit insurance plan, i.e., a health insurance carrier, then that health insurance carrier would be the payer responsible for defendant’s billing invoice. The health insurance carrier would have, by contract with the defendant, been responsible "in whole or in part" for the payment of services rendered to or on behalf of the defendant by plaintiff.
According to defendant’s trial testimony and special defense, prior to and after June 2016, he was a hospital patient covered "in whole or in part for the payment of" hospital services by a health insurance carrier legal entity. However, for defendant’s hospital dates of service for June 6 through June 9, 2016, without the benefit of a health insurance carrier legal entity payer he, by definition, became the only payer pursuant to § 19a-646(a)(4). There is no dispute that just because the plaintiff was statutorily obligated to invoice plaintiff $17,650 pursuant to statute, there was no statutory or otherwise prohibition for the parties to come to a mutually agreeable compromise sum that would be considered by plaintiff as payment in full. No compromised amount was reached by the parties. As the defendant testified on his direct, the same information defendant had made known to the plaintiff over the course of collection efforts, he paid $700 a month for health insurance, paid through June 2016. He learned in July 2016 that, retroactively to May 31, 2016, his health insurance coverage benefit for the month of June 2016 had been terminated. He was refunded by his insurance carrier the $700 premium prepaid for the June 2016 coverage. Defendant knew that on his dates of service he had an approximately $2,000 insurance plan deductible obligation. Plaintiff’s witness Stephanie Pardovich testified why it was impossible to determine defendant’s total bill for dates of service "if he had insurance" as posed by defendant.
For those reasons stated judgment should enter for plaintiff as alleged in its complaint for money damages, costs of suit, both prejudgment and postjudgment percent judgment interest pursuant to General Statute § 37-3a and applicable case law, and an order for weekly payments pursuant to § 52-356(c).
DEFENDANT’S POSITION
The defendant, much to his credit, readily admitted that the plaintiff has provided the medical services and medication to him as claimed, but feels that the amount demanded by plaintiff is unfair and excessive, given the fact that health care insurance companies would be paying the plaintiff significantly less under their payment agreement with the plaintiff healthcare provider. The defendant feels that he should be only required to pay that amount that would have been paid by the health insurance carrier, had the insurance been in force during the month of June 2016.
LEGAL ANALYSIS
The court can wholeheartedly sympathize with the defendant, where payment of medical services rendered to individuals or their family members were not covered by health insurance. However, regardless of how sympathetic the court may be to the defendant’s plight, the court is obligated to only look at, and apply the appropriate statutory, and case law for guidance as to the proper amount of damages owed by the defendant to the plaintiff.
In the case of Caraballo v. Electric Boat Corp., 315 Conn. 704, 110 A.3d 321 (2015), the Supreme Court provided guidance as to how this type of claim must be decided. "Under the public health scheme ... § 19a-646(b) provides: ‘No hospital shall provide a discount or different rate or method of reimbursement from the filed rates or charges to any payer except as provided in this section.’ Any payer may directly negotiate with a hospital for a different rate or method of reimbursement, or both, provided the charges and payments for the payer are on file at the hospital business office in accordance with this subsection ...’ General Statutes § 19a-646(c)(1). A ‘payer’ is broadly defined ... General Statutes § 19a-646(a)(4). Additionally, the public health scheme imposes a civil penalty for a hospital’s noncompliance with the dictates of § 19a-646. See General Statutes § 19a-681 (requiring hospitals to file current pricemaster list, i.e., its detailed schedule of charges for its services, with Office of Health Care Access and providing that, ‘[if] the billing detail by line item on a detailed patient bill does not agree with the detailed schedule of charges on file with the office for the date of service specified on the bill, the hospital shall be subject to a civil penalty of five hundred dollars per occurrence’). Thus, under the scheme applicable to the present case, the only time that a hospital may deviate from its published rates- or else be subject to a civil penalty- is when: (1) a payer has negotiated with the hospital to pay a different rate, or (2) the legislature has expressly provided different rates in the hospital scheme. In the second circumstance, even when payment is dictated under another statutory scheme- for instance, Medicare or Medicaid- the exclusion from chapter 368z was made explicit by the legislature. See General Statutes § 19a-646(a)(4) (excluding Medicare and Medicaid from definition of ‘[p]ayer’); see also General Statutes § 19a-673 (specifying rate hospitals may charge to low income uninsured patients). No such exclusion is provided for ... Assuming ... that what it ‘actually costs’ a hospital to render services to a particular patient ... is different than the hospital’s billed rates, and, therefore, that there is a direct conflict between these two schemes, there is clear evidence that the hospital rates control." Id., 725-26.
The law allows healthcare insurance companies to negotiate lower rates for its subscribers, as provided for in the Caraballo case above, and provided the charges and payments for the payer are on file at the hospital business office, the lower rates may be paid by the insurer. Unfortunately, unless this defendant had such an agreement with the plaintiff, which he did not, he must, by General Statutes and the above-referenced case law, pay the invoice amount as submitted by the plaintiff. This court does not have the authority to disregard the above General Statutes and case law and order the defendant to pay a lesser amount. Given the foregoing analysis, the court, again, being most sympathetic to the plight of the defendant, is bound by General Statutes and case law interpretation of how private payers, such as the defendant, are required to pay the hospital rates for medical services and medications provided to them.
CONCLUSION
Based on the foregoing, it is the decision of this court that judgment shall render in favor of the plaintiff against the defendant, in the amount of $17,650 plus costs as follows: entry fee $360 and marshal’s fees of $77.10, for a total due of $18,087.10. No prejudgment or postjudgment interest is awarded. Defendant shall make weekly payments in the amount of $35 per week, beginning on November 1, 2019 and every week thereafter until paid in full. Payments shall be made payable to plaintiff’s counsel, and sent to plaintiff’s counsel’s address.